ADJ14305554 · June 9, 2026

The Appeals Board found the December 3, 2024 UR determination was untimely under Labor Code section 4610 and former AD Rule 9792.9.1(f), requiring further development of the record with current medical evidence to determine medical necessity. The WCJ erred in dismissing the request as untimely without considering applicant's medical evidence.

From the decision · page 4II Section 4600(b) provides that "medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27." (Lab. Code, § 4600(b).) Section 5307.27 specifies that these guidelines refer to the Medical Treatment Utilization Schedule (MTUS). (Lab. Code, § 5307.27(a).) The MTUS can be found in AD Rules 9792.20 through 9792.27.23 (Cal. Code Regs., tit. 8, § 9792.20-9792.27.23). The MTUS is presumptively correct on the extent and scope of treatment and is the primary source of guidance for physicians. (Lab. Code, § 4604.5(a); Cal. Code Regs., tit. 8, § 9792.21(c).) However, the MTUS may be rebutted, and treatment may be warranted based on recommendations outside the MTUS in limited situations. (Cal. Code Regs., tit. 8, § 9792.21(d); see also Lab. Code, § 4604.5(d).) If a UR decision is untimely, the determination of medical necessity must be made by the WCAB based on substantial medical evidence consistent with the MTUS. (Dubon II, supra, 79 Cal.Comp.Cases at 1300.)

The December 3, 2024 UR determination was not timely under Labor Code section 4610 and former AD Rule 9792.9.1(f).

Favours Applicant prevailed

This untimeliness required the WCAB to determine medical necessity based on substantial medical evidence, not simply dismiss the request as untimely.

From the decision · page 4II Section 4600(b) provides that "medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27." (Lab. Code, § 4600(b).) Section 5307.27 specifies that these guidelines refer to the Medical Treatment Utilization Schedule (MTUS). (Lab. Code, § 5307.27(a).) The MTUS can be found in AD Rules 9792.20 through 9792.27.23 (Cal. Code Regs., tit. 8, § 9792.20-9792.27.23). The MTUS is presumptively correct on the extent and scope of treatment and is the primary source of guidance for physicians. (Lab. Code, § 4604.5(a); Cal. Code Regs., tit. 8, § 9792.21(c).) However, the MTUS may be rebutted, and treatment may be warranted based on recommendations outside the MTUS in limited situations. (Cal. Code Regs., tit. 8, § 9792.21(d); see also Lab. Code, § 4604.5(d).) If a UR decision is untimely, the determination of medical necessity must be made by the WCAB based on substantial medical evidence consistent with the MTUS. (Dubon II, supra, 79 Cal.Comp.Cases at 1300.)

Applicant's medical reports from Dr. Pourtaheri were improperly excluded by the WCJ but are relevant to medical necessity.

Favours Applicant prevailed

The Appeals Board ordered these reports to be admitted and considered, and further medical evidence to be developed.

From the decision · page 2FACTS At trial, the parties agreed to submit issues including permanent disability, apportionment, need for further medical treatment, and applicant's contention that the UR determination non- certifying shoulder surgery was untimely. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 40-41; Pre-Trial Conference Statement dated October 21, 2025, page 3.) The WCJ chose to bifurcate the trial and submit only the issue of whether the applicant's request for authorization of shoulder surgery was timely denied, and if not, whether or not it is reasonably necessary to treat applicant's admitted industrial injury of April 15, 2019 to her neck, bilateral shoulders, back, and bilateral wrists while employed as a department manager for defendant. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 8-16 and 40-47.) At trial, the WCJ admitted the UR determination of December 3, 2024 as Defense Exhibit A. The UR determination, unfavorable to applicant, indicates on its face that the request for authorization was received on November 22, 2024, a completed medical record was received on November 29, 2024, and the date of the decision to non-certify a left shoulder replacement, biceps tenotomy, and surgical assistant was December 3, 2024.

Recommended left shoulder total replacement and left biceps tenotomy surgery; reports were offered but initially not admitted by WCJ; Appeals Board found these reports should have been admitted and considered, and a supplemental report should be solicited for current medical evidence.

The medical evidence from Dr. Pourtaheri was relevant to the determination of medical necessity for the requested surgery and was improperly excluded by the WCJ. The Appeals Board ordered further development of the record including her reports.

From the decision · page 2FACTS At trial, the parties agreed to submit issues including permanent disability, apportionment, need for further medical treatment, and applicant's contention that the UR determination non- certifying shoulder surgery was untimely. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 40-41; Pre-Trial Conference Statement dated October 21, 2025, page 3.) The WCJ chose to bifurcate the trial and submit only the issue of whether the applicant's request for authorization of shoulder surgery was timely denied, and if not, whether or not it is reasonably necessary to treat applicant's admitted industrial injury of April 15, 2019 to her neck, bilateral shoulders, back, and bilateral wrists while employed as a department manager for defendant. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 8-16 and 40-47.) At trial, the WCJ admitted the UR determination of December 3, 2024 as Defense Exhibit A. The UR determination, unfavorable to applicant, indicates on its face that the request for authorization was received on November 22, 2024, a completed medical record was received on November 29, 2024, and the date of the decision to non-certify a left shoulder replacement, biceps tenotomy, and surgical assistant was December 3, 2024.

Labor Code section 4610

Labor Code section 4610 requires timely utilization review decisions within five business days or 14 days from the medical recommendation; failure to comply renders the UR determination untimely.

The December 3, 2024 UR determination was not timely under section 4610 and former AD Rule 9792.9.1(f), requiring further medical evidence to determine necessity.

From the decision · page 4II Section 4600(b) provides that "medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27." (Lab. Code, § 4600(b).) Section 5307.27 specifies that these guidelines refer to the Medical Treatment Utilization Schedule (MTUS). (Lab. Code, § 5307.27(a).) The MTUS can be found in AD Rules 9792.20 through 9792.27.23 (Cal. Code Regs., tit. 8, § 9792.20-9792.27.23). The MTUS is presumptively correct on the extent and scope of treatment and is the primary source of guidance for physicians. (Lab. Code, § 4604.5(a); Cal. Code Regs., tit. 8, § 9792.21(c).) However, the MTUS may be rebutted, and treatment may be warranted based on recommendations outside the MTUS in limited situations. (Cal. Code Regs., tit. 8, § 9792.21(d); see also Lab. Code, § 4604.5(d).) If a UR decision is untimely, the determination of medical necessity must be made by the WCAB based on substantial medical evidence consistent with the MTUS. (Dubon II, supra, 79 Cal.Comp.Cases at 1300.)

Labor Code section 4600(b)

Labor Code section 4600(b) defines medical treatment reasonably required to cure or relieve effects of injury, based on MTUS guidelines.

Medical necessity determination must be consistent with MTUS guidelines as primary source of guidance for physicians.

From the decision · page 4II Section 4600(b) provides that "medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker's injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27." (Lab. Code, § 4600(b).) Section 5307.27 specifies that these guidelines refer to the Medical Treatment Utilization Schedule (MTUS). (Lab. Code, § 5307.27(a).) The MTUS can be found in AD Rules 9792.20 through 9792.27.23 (Cal. Code Regs., tit. 8, § 9792.20-9792.27.23). The MTUS is presumptively correct on the extent and scope of treatment and is the primary source of guidance for physicians. (Lab. Code, § 4604.5(a); Cal. Code Regs., tit. 8, § 9792.21(c).) However, the MTUS may be rebutted, and treatment may be warranted based on recommendations outside the MTUS in limited situations. (Cal. Code Regs., tit. 8, § 9792.21(d); see also Lab. Code, § 4604.5(d).) If a UR decision is untimely, the determination of medical necessity must be made by the WCAB based on substantial medical evidence consistent with the MTUS. (Dubon II, supra, 79 Cal.Comp.Cases at 1300.)

Labor Code section 5909

Labor Code section 5909 requires the Appeals Board to act on petitions for reconsideration within 60 days of case transmission.

The Appeals Board acted within the 60-day period after case transmission on April 13, 2026, granting reconsideration timely.

From the decision · page 3Former Labor Code1 section 5909 provided that a petition for reconsideration was deemed denied unless the Appeals Board acted on the petition within 60 days from the date of filing. (Lab. Code, § 5909.) Effective July 2, 2024, section 5909 was amended to state in relevant part that:

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II)

Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II) establishes that if a UR decision is untimely, the WCAB must determine medical necessity based on substantial medical evidence consistent with MTUS.

The WCAB must determine medical necessity when UR is untimely, requiring further medical evidence development.

From the decision · page 1Applicant contends that the evidence required the WCJ to find that the UR determination was untimely under Labor Code section 4610, and that accordingly, as permitted by the Appeals Board's en banc holding in Dubon v. World Restoration, Inc., et al. (2014) 79 Cal.Comp.Cases 1298 (Dubon II), the WCJ should have found that the requested treatment, a left shoulder total replacement and left biceps tenotomy surgery, is reasonable and necessary based on medical reports that were offered into evidence but neither admitted nor considered by the WCJ.

Applicant's medical reports from Dr. Pourtaheri were offered but not admitted by the WCJ, which was an error; these reports are relevant to medical necessity.

From the decision · page 2FACTS At trial, the parties agreed to submit issues including permanent disability, apportionment, need for further medical treatment, and applicant's contention that the UR determination non- certifying shoulder surgery was untimely. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 40-41; Pre-Trial Conference Statement dated October 21, 2025, page 3.) The WCJ chose to bifurcate the trial and submit only the issue of whether the applicant's request for authorization of shoulder surgery was timely denied, and if not, whether or not it is reasonably necessary to treat applicant's admitted industrial injury of April 15, 2019 to her neck, bilateral shoulders, back, and bilateral wrists while employed as a department manager for defendant. (Minutes of Hearing and Summary of Evidence dated December 30, 2025, page 2, lines 8-16 and 40-47.) At trial, the WCJ admitted the UR determination of December 3, 2024 as Defense Exhibit A. The UR determination, unfavorable to applicant, indicates on its face that the request for authorization was received on November 22, 2024, a completed medical record was received on November 29, 2024, and the date of the decision to non-certify a left shoulder replacement, biceps tenotomy, and surgical assistant was December 3, 2024.